Fraud Waste & Abuse Specialist

Job Description

Job Description

Who we are

At Blue Cross Blue Shield Global SolutionsSM (BCBS Global SolutionsSM), we make it easy for people and organizations to access and pay for healthcare abroad. By combining digital innovation with human-centered care, we go above and beyond for our customers and deliver an international healthcare experience that’s simple, efficient, and human. Whether our customers live, work, travel or study abroad, we give them the confidence and peace of mind to embrace every journey and say “yes” to new possibilities.

We are hiring for a Fraud, Waste and Abuse Specialist to join the team! The Fraud, Waste and Abuse (FWA) Specialist is responsible for the day-to-day execution of our enhanced claim control strategies. The Specialist is on the front line of the company's efforts to reduce unnecessary medical spending and make healthcare more affordable for everyone. The primary responsibility will be to evaluate claim submissions for evidence of fraud, waste, or abuse using an ever-increasing set of tools and techniques, none more important than good judgement and creative problem solving.

Responsibilities:

• Evaluate claims and determine the most appropriate remedy for preventing fraud, waste or abuse, if applicable.
• Contact external 3rd parties through outbound call or email to verify claim information.
• Support negotiations on high-cost claims with non-contracted providers.
• Validate accuracy of claim charges and initial processing decisions.
• Coordinate activities across other departments (ex. Clinical, Provider Finance, Global Service Center, Claims) and external entities (ex., home plans) to ensure successful resolution of claim interventions.
• Determine if claim costs are Usual, Customary and Reasonable through comparative analysis with historic claims.
• Perform online research to fill in gaps in existing tools and understanding.
• Support attempts to obtain written confirmation of falsified claims through independent investigation and recorded interviews/interrogations.
• Perform analysis on historic claims to determine the full scope of identified suspicious activity.
• Track activity and produce reports to measure impact and document actions.
• Other duties as assigned.

Requirements:

• Bachelor’s degree or equivalent experience required; advanced degree or certification valued.
• Minimum of 3 years insurance industry experience required; 5-10 preferred.
• Prior FWA experience highly valued but not required.
• Strong attention to detail and problem-solving skills.
• Strong working knowledge of international health insurance claims.
• Knowledge of US Domestic health insurance claims is a plus.
• Previous experience navigating the company's various claim systems is a significant plus.
• Prior experience identifying or investigating fraud, waste, and abuse is not required, but is highly valued.
• Excellent written and verbal communication skills.
• Strong organizational skills, with the ability to manage multiple competing tasks at the same time.
• Ability to manage ambiguity and drive for resolution.
• Willingness and ability to learn and apply new skills.
• Multilingual strongly preferred.
• Employee is required to have at minimum an internet speed of 75 Mbps (standard high-speed internet access).

What you’ll get in return:

• Competitive annual salary based on experience within a similar role
• Annual bonus
• Competitive medical plans
• Telemedicine available
• Paid parental leave
• Employee assistance and wellness support 24/7
• Free international healthcare coverage

Other Great Perks:

• Hybrid work model
• Work abroad arrangements available
• Generous PTO accrual program with carry-over option
• 9 paid holidays in addition to one floating holiday and one volunteer day
• Tuition reimbursement
• Career/Learning and development opportunities
• 401(k) with generous company match
• Pet insurance offerings
• Identity theft and legal coverages available
• Emphasis on well-being (Virtual well-being platform, monthly mindfulness events, and giveaways)